Three decades of research in the United States indicates that elderly Americans who are dying often spend their final days in pain and receiving treatments they would not choose. One in four elderly Americans die in or shortly after discharge from an intensive care unit. An expanding body of literature documents that physician-family communication and end-of-life care is poor in intensive care units. These deficiencies are associated with high rates of adverse psychological outcomes among family members, physician-family conflict, and treatment that is inconsistent with patients' goals and preferences. Unfortunately, there is a lack of information on practical, generalizable interventions that effectively improve this important aspect of care for elderly patients and their families. The candidate has completed clinical training in pulmonary and critical care medicine, a Master's degree in quantitative and qualitative research methods, and a fellowship in bioethics. The candidate's goals are 1) to develop into an independent investigator in aging research testing interventions to improve outcomes for critically ill elders and their families and 2) to help establish the field of geriatric critical care. The candidate proposes a single-center randomized controlled trial of a multi-faceted communication intervention to improve outcomes for critically ill elders and their families. The 4-component intervention is grounded in self- efficacy theory and centers on the use of a communication coach to provide communication skills training to families and tailored feedback about families' needs to clinicians. The specific aims are to evaluate the effect of the intervention on 1) family members' psychological outcomes; 2) the quality of clinician-family communication and decision-making and 3) the use of life sustaining technologies. We will undertake a careful mixed methods assessment of process outcomes to understand how the intervention changes care. The candidate has assembled a team of accomplished mentors with expertise in geriatrics, critical care medicine, nursing, communication sciences and medical decision-making. He will pursue focused training to develop expertise in aging paradigms, the conduct of hospital-based interventions for elders, and the development and implementation of behavioral health interventions. In light of the growing elderly population and the well known deficiencies in end-of-life care in ICUs, the research addresses a topic of high public health importance. If effective, the intervention would be broadly applicable and would lend valuable insight on an aspect of the care of elderly patients that has proven difficult to improve.